A C ase Study of Bronchial Asthma In Acute Exacerbation

Submitted by: Neil Aaron D.G. Corpuz BSN 3Y1-2

I.

Medication History: Past and Present

History of Present Illness: Few minutes PTA, patient experienced sudden chest pain, radiating to the back 10/10 in severity, it is associated with difficulty of breathing. No associated with dizziness, LOC, blurring of vision, cough and colds. He was nebulized with Salbutamol which afforded no relief. Persisitence of the above signs and symptoms prompted consult. PMH: (+) asthma medication: Salbutamol (+) HPN medication: Amlodipine (-) allergies FH: Unremarkable PSH: Non-smoker Occasional (Alcoholic beverage drinker)

Last attack: 3 weeks ago (dx>10 years ago)

II.

Diagnosis or Impression
Impression: Bronchial Asthma in acute exacerbation, Hypotension Stage II uncontrolled.

III.

Pathophysiology
Chief Complaint: Chest Pain Patient is known asthmatic with last major attack last year for which he was admitted at our institution and given maintenance medication for which he is compliant, but stopped the inhaler. 1 day PTA ------------- (+) colds, (+) difficulty of breathing, (+) cold clammy skin Conscious, medium built BP: 220/120, CR: 101, RR: 25, T: 36.2 Anicteric Sclera, (+) nal discharges

Symmetrical chest expansive, (+) wheezes are on both lungs Apical beat at the 5th ECS, MCL, tachycardia, regular rhythm S1bS2 NABS (-) edema, (-) cyanosis Bronchial asthma in acute exacerbation t/c Pneumothorax and ACS HPN uncontrolled

P> - Nebulization - Trop + - Chest X-ray

IV.

Laboratory Tests and Results

Clinical Microscopy: Urinalysis Macroscopic: Color: Yellow Transparency: Slightly Turbid Microscopic: RBS: 0-2/HPF PUS cells: 0-2/HPF Bacteria: Few Epithelial cells: Few Mucus Threads: Few Chemical: Specific: 1.005 pH: 6.5 Nitrite: (-) Negative Protein: (-) Negative Glucose: (-) Negative Ketone: (-) Negative Urobilinogen: Normal Bilirubin: (-) Negative Leukocytes: (-) Negative

Blood: (-) Negative Hematolgy

CBC: WBC Differential Count Neutrophil Lymphocytes Monocytes Eosinophils Basophils Hemoglobin Hematocrit RBC MCV MCH MCHC RDW Platelet MPV

Result: 9.7 0.31 0.49 0.09 0.08 0.03 154 0.44 5.2 86 29.7 347 12.5 255 4.16

Normal Values: 5.0 - 10.0 x10 g/L 0.40 0.60 0.20 0.40 0.02 0.08 0.01 0.03 0 0.2 140 175 g/L 0.42 0.48 5.5 6.5 x10 g/L 88-96 27.33 300 360 g/L 12.7 22.7% 150 450 x10 g/L 4.5 7.5

Please admit to ROC lender the service of Dr. X Guevara (medicard) Secure consent for admission & mgt. TPR & Shift IVF: DBW 500cc x KVO Soft Hypoallergenic diet

V.

Diagnostic Procedures - Chest X-ray - 12 LECG - CBC TFK - ABG req. - Spirometer - Urinalysis

- Trop T, Qualitative - Crea and electrolytes - FBS, TG, TC, LDl, HDL
VI.

Medical Management
1) 2) 3) 4) 5) Salbutamol nebulization Hydrocortisone 200 mg. now then 100 mg. IV q8 Amynophilline drip at 10 gtts./min. Dolcet tablet q8 for pain Amlodipine 5 mg. 1 tab now then OD CBR with bathroom priveldges O2 at 2 LPM via nasal cannula IPO Monitor VS q1 Admitting Hx RPE c/o Complete database q0 CIC

VII.

Drug Study Indications:

> To control and
prevent reversible airway obstruction caused by asthma or chronic obstructive pulmonary disorder (COPD). > Quick relief for bronchospasm. > For the prevention of exercise-induced bronchospasm.

Drug Study: Salbutamol

Contraindications:
> Hypersensitivity to
adrenergic amines. > Hypersensitivity to fluorocarbons.

Side Effect and Adverse Effect:

1. 2. 3. 4. 5. 6. 7. 8. Nervousness Restlessness Tremor Headache Insomnia Chest pain Palpitations Angina

9. Arrhythmias 10. Hypertension 11. Nausea and vomiting 12. Hyperglycemia 13. Hypokalemia

> To prevent and

Hydrocortisone

relieve symptoms of acute bronchial asthma and treatment of bronchospasm associated with chronic bronchitis and emphysema.

> Contraindicated in patients with hypersensitivity to drug or its ingredients.

1. Tachycardia 2. Tremor 3. Petechiae

> To prevent and

Aminophylline

relieve symptoms of acute bronchial asthma and treatment of bronchospasm associated with chronic bronchitis and emphysema.

> Contraindicated in patients with hypersensitivity to drug or its ingredients.

1. Severe allergic reaction 2. Diarrhea 3. Confusion 4. Fast Breathing 5. Headaches 6. Vomiting 7. Nausea

> Moderate to moderately severe pain

> Contraindicated in patients with hypersensitivity to drug or its ingredients.

Dolcet

1. Drowsiness 2. Nausea 3. Dizziness 4. Constipation 5. Headache 6. Vomiting 7. Diarrhea 8. Dry Mouth 9. Fatigue 10. Indigestion 11. Seizure

Amlodipine

> used to manage o hypertension, chronic stable angina, and vasospastic angina. It may be used alone or with other antihypertensives or antianginals.

> Contraindicated in patients o

1. Peripheral Edema 2. Headache 3. Flushing 4. Dizziness 5. Palpitations 6. Nausea 7. Chest Pain 8. Unusual tiredness or weakness 9. Bradycardia 10. Orthostatic Hypotension

o with hypersensitivity to drug or

its ingredients.

o o o o o o o o

Assessment Subjective: (none) Objective: Immobility Weakness

Nursing Diagnosis Risk for Activity Intolerance r/t decrease oxygenation

Scientific Explanation Inadequate oxygen in the circulation can develop weakness in our muscles. Muscles need oxygen to move and to do its function. If the patient cannot tolerate any activities because of the low oxygenation caused by the ventilationperfusion imbalance caused by the pathological minimized lung expansion.

Planning Choose: Patient will participate willingly in necessary/ desired activities such as deep breathing exercises.

Interventions 1. Monitor VS.

Rationale

Evaluation Patient will participate willingly in necessary/ desired activities such as deep breathing exercises. Patient will perform ADLs within clients ability and participates in desired activities. Patient will be able to increase activity tolerance AEB attendance of selfcare needs. Patient will be able to gradually increase activity within level of ability (change will to shall then shift to past tense)

1. For baseline 2. Assess data. motor 2. To function. identify 3. Note causative contributing factors. factors to 3. To fatigue. identify 4. Evaluate precipitati degree of ng deficit. factors. 4. To identify severity. 5. To identify necessity of assistive devices. 6. Stress and/or depressio n may increase the effects of illness. 7. To reduce fatigue

Patient will 5. Ascertain perform ability to ADLs stand and within move clients about. ability and 6. Assess participates emotional in desired or activities. psychologic al factors Patient will 7. Plan care be able to with rest increase periods activity between tolerance activities AEB 8. Increase attendance activity/exe of self-care rcise needs. gradually such as Patient will assisting be able to the patient gradually in doing increase PROM to activity active or within level full range of of ability motions. 9. Provide adequate rest periods. 10. Assist client in doing self

8. Minimizes muscle atrophy, promotes circulatio n, helps to prevent contractu res

care needs 9. To replenish energy. 10. To promote independ ence and increase activity tolerance 11. Promotes venous 12. Maintains functional position

11. Elevate arm and hand 12. Place knees and hips in extended position

Assessment Subjective: (none) Objective: wheezi ng upon inspirati on and expirati on dyspne a coughin g, sputum is yellow and sticky tachypn ea, prolong ed expirati on tachyca rdia chest tightne ss suprast ernal retracti on restless ness anxiety cyanosi s loss of conscio usness

Nursing Diagnosis Ineffective airway clearance RT bronchoconstri ction, increased mucus production, and respiratory infection AEB wheezing, dyspnea, and cough

Scientific Explanation The presence of a foreign microorganism triggers the B lymphocyte to produce antibodies that are specific to that antigen. These antibodies then attach to mast cells in the lungs. The mast cells with the antibody attaches to the antigen and begins to degranulate. This degranulation causes the release of certain chemical mediators, namely, histamine, bradykinin, prostaglandin, and leukotriene. These chemical mediators cause bronchospasm leading to bronchoconstri ction, increased vascular permeability leading to fluid leakage from the lung

Planning Choose: Patient will maintain/im prove airway clearance AEB absence of signs of respiratory distress Patient will verbalize understandi ng that allergens like dust, fumes, animal dander, pollen, and extremes of temperature and humidity are irritants or factors that can contribute to ineffective airway clearance and should be avoided. Patient will demonstrate behaviors that would prevent the recurrence of the problem

Interventions 1. Adequately hydrate the pt. 2. Teach and encourage the use of diaphragma tic breathing and coughing exercises. 3. Instruct pt to avoid bronchial irritants such as cigarette smoke, aerosols, extremes of temperatur e, and fumes. 4. Teach early signs of infection that are to be reported to the clinician immediatel y. Increas es sputum product ion Change in color of sputum Increas ed

Rationale 1. Systemic hydration keeps secretion moist and easier to expectora te. 2. These technique s help to improve ventilatio n and mobilize secretions without causing breathless ness and fatigue. 3. Bronchial irritants cause bronchoco nstriction and increased mucus productio n, which then interfere with airway clearance. 4. Minor respirator y infections that are of no conseque nce to the person with

Evaluatio n Short Term: The pt shall be free from any signs of respirator y distress

Long Term: The patient shall have demonstr ated behaviors and understoo d causative factors to prevent recurrenc e of problem.

vasculature and increased mucus production. These lead to swelling of the bronchi, mucus buildup that plugs the airway and decreased bronchial diameter. This causes an increased airway resistance and a constricted pathway for air. Air cannot pass effectively and this manifests as a whistling sound. Coughing is a way to expel the obstruction (mucus plug) while dyspnea is a manifestation of the increased airway resistance.

thickne ss of sputum Increas ed SOB, tightne ss of chest, or fatigue Increas ed coughin g Fever or chills

5. If indicated, perform postural drainage with percussion and vibration in the morning and at night as prescribed. 6. Assist in administeri ng nebulizer, as indicated. 7. Administer ATX as prescribed.

normal lungs can produce fatal disturbanc es in the lungs of an asthmatic person. Early recognitio n is crucial. 5. Uses gravity to help raise secretions so they can be more easily expectora ted.

6. This ensures adequate delivery of medicatio ns to the airways.

7. Antibiotics may be prescribed to treat the infection.